Relationships Among Stress, Diabetes Distress, and Biomarkers in Children with Type 1 Diabetes Mellitus from Diverse Income and Racial Backgrounds.

INTRODUCTION: The purpose of this quantitative study was to consider factors that may negatively impact glycemic levels in Black and White children 8-12 years old with a diagnosis of type 1 diabetes mellitus. METHOD: Perceived stress, diabetes distress, morning and afternoon salivary cortisol, inflammatory biomarkers, and hemoglobin A1c (HbA1c) were measured in this quantitative, cross-sectional phase of a larger, mixed methods study. Thirty-four children and their parents completed self-report surveys, and children provided blood and salivary samples, to examine effect sizes of relationships among variables of interest. RESULTS: Most children did not meet ADA recommendations for HbA1c. HbA1c was higher in Black children. Medium-to-large effects were noted between perceived stress and HbA1c. Cortisol and IL-8 may mediate the relationship between perceived stress and HbA1c in children. DISCUSSION: Understanding causes of elevated glycemic levels in children, especially from low-income and underrepresented populations, may help tailor diabetes management interventions to improve health outcomes.

Spatiospectral image processing workflow considerations for advanced MR spectroscopy of the brain.

Magnetic resonance spectroscopy (MRS) is one of the few non-invasive imaging modalities capable of making neurochemical and metabolic measurements in vivo. Traditionally, the clinical utility of MRS has been narrow. The most common use has been the "single-voxel spectroscopy" variant to discern the presence of a lactate peak in the spectra in one location in the brain, typically to evaluate for ischemia in neonates. Thus, the reduction of rich spectral data to a binary variable has not classically necessitated much signal processing. However, scanners have become more powerful and MRS sequences more advanced, increasing data complexity and adding 2 to 3 spatial dimensions in addition to the spectral one. The result is a spatially- and spectrally-variant MRS image ripe for image processing innovation. Despite this potential, the logistics for robustly accessing and manipulating MRS data across different scanners, data formats, and software standards remain unclear. Thus, as research into MRS advances, there is a clear need to better characterize its image processing considerations to facilitate innovation from scientists and engineers. Building on established neuroimaging standards, we describe a framework for manipulating these images that generalizes to the voxel, spectral, and metabolite level across space and multiple imaging sites while integrating with LCModel, a widely used quantitative MRS peak-fitting platform. In doing so, we provide examples to demonstrate the advantages of such a workflow in relation to recent publications and with new data. Overall, we hope our characterizations will lower the barrier of entry to MRS processing for neuroimaging researchers.

Changes in Self-Efficacy During COVID-19 Among Adolescents With Type 1 Diabetes Mellitus: A Qualitative Study.

INTRODUCTION: The purpose of this longitudinal, qualitative study was to examine the impact of the COVID-19 pandemic on self-efficacy and diabetes management among youth diagnosed with type 1 diabetes mellitus (T1DM). METHODS: We conducted two semi-structured interviews with adolescents diagnosed with T1DM (n = 18) and their maternal caregivers (n = 20) over 6-9 months, to understand how their confidence in the adolescent's ability to manage their diabetes changed during the pandemic. Interviews were transcribed and coded by four raters, establishing inter-reliability. RESULTS: Four themes emerged: Preventing Adverse Glycemic Events, Useful Glucose Trend Information, Improved Diabetes Management, and Downsides of Technology. Most adolescents (63%) reported increased confidence in their ability to manage diabetes during the pandemic. Over half of these adolescents were already using an insulin pump, and a substantial number (33%) updated their insulin delivery method. Both adolescents and caregivers cited diabetes devices as a factor in their self-efficacy for diabetes management. DISCUSSION: Findings illustrate the importance of diabetes management in the daily lives of adolescents diagnosed with T1DM, and the potential benefits of diabetes devices during disruptions to care.

Time for a Reframe: Shifting Focus From Continuous Glucose Monitor Uptake to Sustainable Use to Optimize Outcomes.

Continuous glucose monitors (CGMs) improve glycemic outcomes and quality of life for many people with diabetes. Research and clinical practice efforts have focused on CGM initiation and uptake. There is limited understanding of how to sustain CGM use to realize these benefits and limited consideration for different reasons/goals for CGM use. Therefore, we apply the Information-Motivation-Behavioral Skills (IMB) model as an organizing framework to advance understanding of CGM use as a complex, ongoing self-management behavior. We present a person-centered, dynamic perspective with the central thesis that IMB predictors of optimal CGM use vary based on the CGM use goal of the person with diabetes. This reframe emphasizes the importance of identifying and articulating each person's goal for CGM use to inform education and support.

Associations of Coping Strategies With Glycemic and Psychosocial Outcomes Among Adolescents With Type 1 Diabetes Experiencing Diabetes Distress.

BACKGROUND: Many adolescents with type 1 diabetes experience diabetes distress which is associated with suboptimal glycemic and psychosocial outcomes. The ways in which adolescents respond to diabetes distress may serve as a risk or protective factor for these outcomes, but few studies have examined the coping strategies adolescents use to manage diabetes distress. PURPOSE: To examine the association of coping strategies with glycemic and psychosocial outcomes among adolescents experiencing diabetes distress. METHODS: Participants included 198 adolescents with elevated diabetes distress who completed baseline data for a randomized controlled trial (Mage = 15.3 ± 1.4, 58% female, 58% non-Hispanic White, MA1c = 9.1 ± 2.1%). Adolescents reported on their use of coping strategies related to diabetes stressors, including primary control engagement coping (e.g., problem-solving), secondary control engagement coping (e.g., positive thinking), and disengagement coping (e.g., avoidance). Adolescents also completed measures of diabetes distress, quality of life, and resilience. HbA1c data were extracted from electronic medical records and at-home kits. RESULTS: Higher use of primary control engagement coping was associated with better glycemic and psychosocial outcomes. Secondary control engagement coping was associated with better psychosocial outcomes but not glycemic outcomes. Greater use of disengagement coping strategies was associated with poorer glycemic and psychosocial outcomes. All associations were significant after adjusting for adolescent sex, age, race/ethnicity, and continuous glucose monitor use. CONCLUSIONS: These results build on prior findings by including a more diverse sample of adolescents and highlight the value of promoting engagement coping strategies and discouraging the use of disengagement coping strategies among adolescents experiencing diabetes distress. CLINICAL TRIAL INFORMATION: NCT03845465.

Many teens with type 1 diabetes (T1D) experience diabetes distress, or the emotional burden related to living with T1D, which can negatively impact their health and overall well-being. However, few studies have explored how adolescents cope with diabetes distress. In the current study, we examined how different coping strategies related to both physical (glycemic) and psychosocial outcomes among adolescents experiencing diabetes distress. We found that using coping strategies focused on active problem-solving (primary control engagement coping) was linked to better glycemic and psychosocial outcomes. Similarly, adopting a positive mindset (secondary control engagement coping) was associated with improved psychosocial well-being but was not associated with glycemic outcomes. Conversely, the use of avoidance strategies (disengagement coping) was linked to poorer outcomes in both areas. These findings highlight the importance of promoting engagement coping strategies and discouraging the use of disengagement strategies among adolescents experiencing diabetes distress, suggesting potential areas for intervention.

Towards the standardisation of adult person-reported outcome domains in diabetes research: A Consensus Statement development panel.

Diabetes is unique among chronic diseases because clinical outcomes are intimately tied to how the person living with diabetes reacts to and implements treatment recommendations. It is further characterised by widespread social stigma, judgement and paternalism. This physical, social and psychological burden collectively influences self-management behaviours. It is widely recognised that the individual's perspective about the impact of trying to manage the disease and the burden that self-management confers must be addressed to achieve optimal health outcomes. Standardised, rigorous assessment of mental and behavioural health status, in interaction with physical health outcomes is crucial to aid understanding of person-reported outcomes (PROs). Whilst tempting to conceptualise PROs as an issue of perceived quality of life (QoL), in fact health-related QoL is multi-dimensional and covers indicators of physical or functional health status, psychological and social well-being. This complexity is illuminated by the large number of person reported outcome measures (PROMs) that have been developed across multiple psychosocial domains. Often measures are used inappropriately or because they have been used in the scientific literature rather than based on methodological or outcome assessment rigour. Given the broad nature of psychosocial functioning/mental health, it is important to broadly define PROs that are evaluated in the context of therapeutic interventions, real-life and observational studies. This report summarises the central themes and lessons derived in the assessment and use of PROMs amongst adults with diabetes. Effective assessment of PROMs routinely in clinical research is crucial to understanding the true impact of any intervention. Selecting appropriate measures, relevant to the specific factors of PROs important in the research study will provide valuable data alongside physical health data.

Observed collaborative and intrusive parenting behaviours associated with psychosocial outcomes of adolescents with type 1 diabetes and their maternal caregivers.

AIMS: Maternal caregiver involvement is strongly associated with psychosocial and glycemic outcomes amongst adolescents with type 1 diabetes (T1D); however, previous studies have lacked detailed, objective examinations of caregiver involvement. We examined the relationship between observed parenting behaviors and psychosocial and glycemic outcomes amongst youth with T1D. METHODS: Data collected from adolescents with T1D (age 11-17) and their female caregivers as a part of a randomized controlled trial were analyzed. These included structured, observation-based scores of adolescent-caregiver dyads engaged in videotaped interactions and selected psychosocial and glycemic outcome measures. RESULTS: In adjusted analyses, higher levels of intrusive parenting behaviors during observed interactions were associated with higher diabetes distress in adolescents, but no difference in HbA1c. Associations between intrusive parenting behaviors and psychosocial outcomes were stronger for females compared to males for both diabetes distress and quality of life. Similarly, associations between collaborative parenting behaviors and quality of life were stronger for female adolescents than males. No associations were observed between collaborative parenting behaviors and glycemic outcomes. Consistent with previous work, we noted higher levels of adolescent-reported family conflict were associated with lower adolescent quality of life and higher diabetes distress with no significant difference between male and female adolescents. CONCLUSION: These findings indicate that high levels of intrusive parenting behaviors, such as lecturing or over-controlling behaviors, are associated with lower levels of adolescent well-being, particularly among adolescent girls. This work suggests that interventions to reduce intrusive parenting by maternal caregivers could result in improved psychosocial outcomes for adolescents with T1D.

Using Community Engagement Methods to Guide Study Protocol Decisions for School-Aged Children With Type 1 Diabetes.

Introduction: Many challenges exist in developing multisite protocols for newly diagnosed children with type 1 diabetes. Our research team engaged community members to increase the likelihood of study success during a planning grant for a longitudinal study aimed at understanding risk and protective factors for neurocognitive function in school-aged children newly diagnosed with type 1 diabetes. Methods: Two methods were used to obtain caregiver input into study protocol decisions. The first was a survey given to caregivers of children with diabetes (n = 21) about which aspects of the study protocol would make families more or less likely to participate. The second was a Community Engagement (CE) Studio to obtain recommendations from a diverse group of caregivers of children with diabetes (n = 7) on key aspects of recruitment and enrollment. Results: Results from both the survey and the CE Studio indicated that caregivers were interested and willing to participate in a longitudinal study of this nature. Both methods resulted in similar preferences for the type and amount of compensation, convenient study visits, flexible scheduling options, and receipt of neurocognitive test results. Recommendations from the CE Studio included additional strategies to minimize participant burden and enhance communication around study participation. Conclusion: Both the feasibility survey and the CE Studio were useful mechanisms to obtain caregiver input during the study's planning and design phase. Uniquely, the CE Studio approach offers researchers the ability to gain valuable community member input with minimal staff effort.

Detangling Associations Between Maternal Depressive Symptoms and Diabetes Relationship Distress With Adolescents' HbA1c.

OBJECTIVE : Previous research in families of children with type 1 diabetes demonstrates that maternal depressive symptoms are a known risk factor for poor diabetes outcomes. We sought to examine whether maternal diabetes relationship distress or maternal depressive symptoms were more strongly associated with adolescent glycemic outcomes. METHODS : Analyses were conducted using data from mothers who consented to screen for a behavioral intervention. The screener included the Patient Health Questionnaire and the Parent Diabetes Distress Scale, Parent/Teen Relationship Distress subscale. Hemoglobin A1c (HbA1c) was extracted from adolescents' medical records. RESULTS : Our sample consisted of 390 maternal caregivers of adolescents with type 1 diabetes aged 11-17. Screening data revealed that 35% of mothers reported clinically significant diabetes distress related to their relationship with their adolescents, and 14% of mothers reported clinically significant depressive symptoms. The adolescents of mothers who reported diabetes relationship distress had significantly higher mean HbA1c levels (9.7 ± 2.2%) compared to those whose mothers were not distressed (8.2 ± 1.8%, d = .72). Similarly, adolescents whose mothers reported clinically significant depressive symptoms had higher mean HbA1c levels (9.6 ± 2.4%) than those whose mothers were not depressed (8.6 ± 2.0%, d = .48). After adjusting for clinical and demographic factors, mothers' reports of diabetes relationship distress were more strongly associated with adolescents' HbA1c than maternal depressive symptoms. CONCLUSIONS : Our findings suggest that screening for maternal distress-particularly distress related to the caregiver-adolescent relationship-could match families with psychosocial support or other resources to improve both psychosocial and glycemic outcomes.

Disparities in Continuous Glucose Monitor Use Between Children With Type 1 Diabetes Living in Urban and Rural Areas.

OBJECTIVE: Despite evidence that continuous glucose monitoring (CGM) use is associated with lower HbA1c among children with type 1 diabetes, uptake of this technology remains lower among those with difficulty accessing health care, including those from lower socioeconomic status backgrounds and racial and ethnic minorities. In this study, we sought to explore the impact of rural location in use of CGM technology to guide patient and provider decision making. RESEARCH DESIGN AND METHODS: In this retrospective study of electronic health record demographic and visits data from a single diabetes program from 1 January 2018 through 31 December 2021, we compared the odds of completing a visit with (+) and without (-) CGM interpretation between rural-urban commuting area (RUCA) designations. RESULTS: Among the 13,645 visits completed by 2,008 patients with type 1 diabetes younger than age 18 years, we found children living in small rural towns had 31% lower odds (6.3% of CGM+ visits, 8.6% of CGM- visits; adjusted odds ratio [aOR] 0.69, 95% CI 0.51-0.94) and those living in isolated rural towns had 49% lower odds (2.0% of CGM+ visits, 3.4% of CGM- visits; aOR 0.51, 95% CI 0.28-0.92) of completing a CGM-billed clinic visit compared with those living in urban areas (70.0% of CGM+ visits, 67.2% of CGM- visits). We also found significant differences in CGM-billed visits by neighborhood deprivation as well as race/ethnicity and insurance payor. CONCLUSIONS: Geographic location presents a meaningful barrier to access to care for patients living with type 1 diabetes. Further work is needed to identify and address the needs of children and families living in rural areas to improve the care of these patients.

Glycemic and Psychosocial Correlates of Continuous Glucose Monitor Use Among Adolescents With Type 1 Diabetes.

BACKGROUND: Continuous glucose monitor (CGM) use has been linked with better glycemic outcomes (HbA1c), yet many adolescents with type 1 diabetes (T1D) struggle to maintain optimal CGM use. METHODS: This study examined CGM use and its association with HbA1c and psychosocial factors among adolescents with T1D experiencing at least moderate diabetes distress (N = 198). We examined mean differences in HbA1c, diabetes distress, diabetes-related family conflict, and quality of life among CGM user groups (Current Users, Past Users, and Never Users). RESULTS: Current Users demonstrated significantly lower HbA1c than Never Users and significantly lower diabetes distress than Past Users. CGM use was not associated with family conflict or quality of life. CONCLUSIONS: CGM use was associated with lower HbA1c and diabetes distress but not with other psychosocial outcomes. Longitudinal data may explain why many adolescents do not experience improvements in quality of life with CGM use.

Spatiospectral image processing workflow considerations for advanced MR spectroscopy of the brain.

Magnetic resonance spectroscopy (MRS) is one of the few non-invasive imaging modalities capable of making neurochemical and metabolic measurements in vivo. Traditionally, the clinical utility of MRS has been narrow. The most common use has been the "single-voxel spectroscopy" variant to discern the presence of a lactate peak in the spectra in one location in the brain, typically to evaluate for ischemia in neonates. Thus, the reduction of rich spectral data to a binary variable has not classically necessitated much signal processing. However, scanners have become more powerful and MRS sequences more advanced, increasing data complexity and adding 2 to 3 spatial dimensions in addition to the spectral one. The result is a spatially- and spectrally-variant MRS image ripe for image processing innovation. Despite this potential, the logistics for robustly accessing and manipulating MRS data across different scanners, data formats, and software standards remain unclear. Thus, as research into MRS advances, there is a clear need to better characterize its image processing considerations to facilitate innovation from scientists and engineers. Building on established neuroimaging standards, we describe a framework for manipulating these images that generalizes to the voxel, spectral, and metabolite level across space and multiple imaging sites while integrating with LCModel, a widely used quantitative MRS peak-fitting platform. In doing so, we provide examples to demonstrate the advantages of such a workflow in relation to recent publications and with new data. Overall, we hope our characterizations will lower the barrier of entry to MRS processing for neuroimaging researchers.

Associations of deep sleep and obstructive sleep apnea with family relationships, life satisfaction, and physical stress experience in children: a caregiver perspective.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) and poor quality of sleep negatively impacts health-related quality of life in adults, but few studies have evaluated the association between sleep disturbance (eg, OSA, inadequate sleep) and health-related quality of life domains (eg, family relations, life satisfaction) in children. METHODS: Children ages 8-17 years referred to a sleep center for routine polysomnography from April 2022 to August 2022 were approached to participate in the study, and children visiting the department of pediatrics for their wellness visit were recruited for comparisons. Statistical analysis was conducted using R 3.6.0. RESULTS: Ninety-nine children were recruited from the sleep clinic, and 23 children were recruited from the primary care clinic. Of these children, 62 were diagnosed with obstructive sleep apnea (31 mild, 12 moderate, 19 severe), and 37 did not meet criteria for a diagnosis. Health-related quality of life domains did not differ across OSA severity levels. Children in general had lower life satisfaction and higher physical stress experience compared to children visiting for their wellness examination (well-child visitors, P = .05 and P = .005, respectively). Children with severe OSA had significantly lower life satisfaction and significantly higher physical stress experience when compared with well-child visitors (P = .008 and P = .009, respectively). Correlation analysis showed that N3 (deep) sleep was positively associated with family relations and life satisfaction, while it was negatively associated with anger. CONCLUSIONS: Based on caregiver response, N3 sleep is positively associated with family relations and life satisfaction and negatively associated with anger. Severe OSA is associated with lower life satisfaction and higher physical stress experience. CITATION: Bhushan B, Zee PC, Grandner MA, et al. Associations of deep sleep and obstructive sleep apnea with family relationships, life satisfaction, and physical stress experience in children: a caregiver perspective. J Clin Sleep Med. 2023;19(12):2087-2095.

Sedentary Behavior and Physical Activity Associated with Psychosocial Outcomes in Adolescents with Type 1 Diabetes.

Background: Adolescents with type 1 diabetes (T1D) are particularly vulnerable to poor psychosocial outcomes-high rates of diabetes distress and poor quality of life are common among this cohort. Previous work in the general population demonstrated positive associations between quality of life and increases in moderate-to-vigorous physical activity (MVPA), as well as decreased sedentary behavior. While survey-based assessments of young adults with T1D observed similar trends, these studies were limited by their use of subjective assessments of MVPA and sedentary behavior. The use of direct activity monitoring is needed to establish the association between psychosocial outcomes and MVPA and sedentary behavior among adolescents with T1D. Objective: To explore the association between objectively measured MVPA and sedentary behavior on psychosocial outcomes among adolescents with T1D. Subjects and Methods: The current study is a secondary analysis of baseline data collected for a pilot trial of sleep-promoting intervention for adolescents with T1D. Participants (n = 29, with a mean age of 15.9 ± 1.3 years) completed baseline surveys and wore an actigraph for a week following the baseline visit. We examined minutes per week of MVPA and proportion of awake time spent sedentary in relation to adolescents' diabetes distress, depressive symptoms, and diabetes-related quality of life. Results: Participants engaged in a mean of 19.6 ± 22.4 minutes of MVPA per day and spent 68.6 ± 9.9% of their awake time sedentary. MVPA was associated with lower diabetes distress in unadjusted (-3.6; 95% CI: -6.4 to -0.8) and adjusted (-2.6; 95% CI: -5.0--0.3) analyses. Sedentary time was associated with higher diabetes distress in adjusted (6.3; 95% CI: 1.3-11.2) but not unadjusted (6.0; 95% CI: -5.6-12.6) analyses. In secondary analyses, we did not observe significant associations between quality of life or depressive symptoms with either MVPA or sedentary behavior. Discussion: Our findings extend previous survey-based work demonstrating an association between decreased diabetes distress with greater weekly MVPA and lower sedentary time. The current study highlights the multifaceted benefits of physical activity in this population and provides preliminary evidence for developing interventions to reduce sedentary time as an alternative method to improve psychosocial outcomes in this at-risk population.

Using Mixed Methods Research in Children with Type 1 Diabetes: a Methodological Review.

PURPOSE OF REVIEW: Many factors influence disease management and glycemic levels in children with type 1 diabetes (T1D). However, these concepts are hard to examine in children using only a qualitative or quantitative research paradigm. Mixed methods research (MMR) offers creative and unique ways to study complex research questions in children and their families. RECENT FINDINGS: A focused, methodological literature review revealed 20 empirical mixed methods research (MMR) studies that included children with T1D and/or their parents/caregivers. These studies were examined and synthesized to elicit themes and trends in MMR. Main themes that emerged included disease management, evaluation of interventions, and support. There were multiple inconsistencies between studies when reporting MMR definitions, rationales, and design. Limited studies use MMR approaches to examine concepts related to children with T1D. Findings from future MMR studies, especially ones that use child-report, may illuminate ways to improve disease management and lead to better glycemic levels and health outcomes.

Importance of caregivers' subjective social status and neighbourhood disadvantage for adolescents with type 1 diabetes.

AIMS: Adolescents with type 1 diabetes from low-income populations are more likely to have difficulty in managing their diabetes and ultimately have poorer glycaemic outcomes, but less is known about neighbourhood-level factors or subjective social status (SSS) as risk/protective factors. We examined associations between multiple indicators of socio-economic status with diabetes outcomes. METHODS: One hundred and ninety-eight adolescents ages 13-17 (58% female, 58% White, non-Hispanic) experiencing moderate diabetes distress completed measures of diabetes management and diabetes distress, and their caregivers reported on SSS. Glycaemic indicators were extracted from medical records, and participants' addresses were used to determine area deprivation index (ADI). RESULTS: Higher levels of neighbourhood disadvantage were significantly associated with higher haemoglobin A1c levels and average glucose levels, but caregivers' SSS was more strongly associated with all glycaemic indicators, diabetes management and diabetes distress. CONCLUSIONS: Given strong associations between caregivers' SSS and glycaemic control, diabetes management, and diabetes distress, screening for caregivers' SSS may identify adolescents who would benefit from additional support.

Prolonged lapses between pediatric and adult care are associated with rise in HbA1c and inpatient days among patients with type 1 diabetes.

AIM: To quantify the association between the duration of the pediatric-to-adult care transfer with glycemic control among patients with type 1 diabetes (T1D). METHODS: This retrospective cohort study included patients with T1D who completed transfer between pediatric and adult diabetes clinics at a single academic medical center between 2004 and 2020. The primary exposure was time from the last pediatric to first adult diabetes care encounter. The primary outcome was the average HbA1c in the first year after entry into adult care. RESULTS: A total of 449 patients (mean age at transfer 19.8yrs, 51.7 % male) were included for analysis. Transfer required a median of nearly 5 months (196 days; IQR:93-251) and in adjusted and unadjusted models was strongly associated with increased HbA1c within 1 year of transfer (0.19 %, 2 mmol/mol; 95 %CI:0.04 %-0.33 %) for each 6 months of latency. In secondary analyses, transfer latency also exhibited a significant association with days spent hospitalized (IRR 1.23 per 6 months; 95 %CI:1.08-1.33). CONCLUSIONS: Our findings isolate and quantify the impact of prolonged lapses in care associated with the pediatric-to-adult care transfer. These findings underscore the need for providers and healthcare systems to improve this care transition in order to improve outcomes for this vulnerable patient population.

Multimodal neuroimaging in pediatric type 1 diabetes: a pilot multisite feasibility study of acquisition quality, motion, and variability.

Type 1 diabetes (T1D) affects over 200,000 children and is associated with an increased risk of cognitive dysfunction. Prior imaging studies suggest the neurological changes underlying this risk are multifactorial, including macrostructural, microstructural, and inflammatory changes. However, these studies have yet to be integrated, limiting investigation into how these phenomena interact. To better understand these complex mechanisms of brain injury, a well-powered, prospective, multisite, and multimodal neuroimaging study is needed. We take the first step in accomplishing this with a preliminary characterization of multisite, multimodal MRI quality, motion, and variability in pediatric T1D. We acquire structural T1 weighted (T1w) MRI, diffusion tensor MRI (DTI), functional MRI (fMRI), and magnetic resonance spectroscopy (MRS) of 5-7 participants from each of two sites. First, we assess the contrast-to-noise ratio of the T1w MRI and find no differences between sites. Second, we characterize intervolume motion in DTI and fMRI and find it to be on the subvoxel level. Third, we investigate variability in regional gray matter volumes and local gyrification indices, bundle-wise DTI microstructural measures, and N-acetylaspartate to creatine ratios. We find the T1-based measures to be comparable between sites before harmonization and the DTI and MRS-based measures to be comparable after. We find a 5-15% coefficient of variation for most measures, suggesting ~150-200 participants per group on average are needed to detect a 5% difference across these modalities at 0.9 power. We conclude that multisite, multimodal neuroimaging of pediatric T1D is feasible with low motion artifact after harmonization of DTI and MRS.

A pragmatic low carbohydrate diet intervention changes neither carbohydrate consumption nor glycemia in adolescents and young adults with type 1 diabetes in a randomized trial.

OBJECTIVE: Despite enthusiasm for low carbohydrate diets (LCDs) among patients with type 1 diabetes (T1DM), no prospective study has investigated outcomes in adolescent T1DM. We aimed to quantify a pragmatic LCD intervention's impact on glycemia, lipidemia, and quality of life (QOL) in adolescents with T1DM. RESEARCH DESIGN AND METHODS: At an academic center, we randomized 39 patients with T1DM aged 13-21 years to one of three 12-week interventions: an LCD, an isocaloric standard carbohydrate diet (SCD), or general diabetes education without a prescriptive diet. Glycemic outcomes included glycosylated hemoglobin (HbA1c) and continuous glucose monitoring. RESULTS: There were no significant differences in glycemic, lipidemic, or QOL parameters between groups at any timepoint. Median HbA1c was similar at baseline between groups and did not change appreciably (7.9%-8.4% in LCDs, 7.9%-7.9% in SCDs, and 8.2%-7.8% in controls). Change in carbohydrate consumption was minimal with only one participant reaching target carbohydrate intake. CONCLUSIONS: This pragmatic LCD intervention did not alter carbohydrate consumption or glycemia. Although this study was unable to evaluate a highly controlled LCD, it indicates that adolescents are unlikely to implement an educational LCD intervention in routine clinic settings. Thus, this approach is unlikely to effectively mitigate hyperglycemia in adolescents.

Demographic and Glycemic Factors Linked With Diabetes Distress in Teens With Type 1 Diabetes.

OBJECTIVE: Diabetes distress (DD) is a negative emotional response related to the burdens of living with type 1 diabetes (T1D) and is linked with diabetes outcomes, such as hemoglobin A1c (A1c). Yet, less is known about how other glycemic indicators, average blood glucose and time in range, relate to DD, and which demographic characteristics are associated with higher DD. METHODS: In total, 369 teens (Mage 15.6 ± 1.4, 51% female, MT1D duration 6.7 ± 3.8 years) screened for DD using The Problem Areas in Diabetes-Teen Version to determine eligibility for an ongoing multi-site behavioral trial. The associations of DD, demographic factors, and glycemic indicators (A1c, average blood glucose, and time in range) were analyzed. RESULTS: Twenty-nine percent of teens (n = 95) scored above the clinical cutoff (≥44) for DD. Females scored significantly higher on average than males. Black/African American, non-Hispanic youth screened significantly higher compared to youth from other racial/ethnic groups. Higher DD scores were related to higher A1c and average blood glucose, and lower time in range. Logistic regression models revealed that females were significantly more likely to report clinically elevated DD than males, and teens with higher A1c were 1.3 times more likely to report DD. Age and diabetes duration were not significantly associated with clinically elevated DD scores. CONCLUSIONS: Results demonstrated that DD is most prevalent in Black, non-Hispanic and female teens, and DD is associated with higher average blood glucose and lower time in range. Further investigation into these disparities is warranted to promote optimal health outcomes for teens with T1D.